Root Cause Tip: Making Team Investigations Work (A “Best of” Article from the Root Cause Network™ Newsletter)
Making Team Investigations Work
Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.
WHY USE A TEAM?
First, team investigations are now required for process safety-related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?
Quite simply because two heads are better than one! Why? Several reasons:
- A team’s resources can more quickly investigate an incident before the trail goes cold.
- For complex systems, more than one person is usually needed to understand the problem.
- Several organizations that were involved in the incident need to participate in the investigation.
- A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrome.)
MAKING THE TEAMWORK
Investigating an incident using a team is different than performing an individual investigation. To make the teamwork, you need to consider several factors:
- Who to include on the team.
- The training required for team members.
- Division of work between team members and coordinating the team’s activities.
- Record keeping of the team’s meetings.
- Software to facilitate the team’s work.
- Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.
WHO’S ON THE TEAM?
The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:
- Engineering/technical assistance for hardware expertise.
- Human engineering/ergonomics experts for human performance analysis.
- Operations/maintenance personnel who understand the work practices.
- An investigation coach/facilitator who is experienced in performing investigations.
- A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
- A union rep.
- A safety professional.
TRAINING THE TEAM
A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgment to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. However, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.
What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…
- Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
- Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
- People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness.
KEEPING ON TRACK
One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger-pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice.
MORE TO LEARN
This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE.
If you have already attended a 5-Day TapRooT® Course, you can learn even more best practices at the Global TapRooT® Summit. Get more Summit info at: